You're right. I imagine some honest people (or suckers depending on your outlook) actually try in earnest to pay their hospital debts. Most people just deal with collections.

As a former poor person with no insurance, I can tell you that actually going to an ER is usually the last resort. The working poor who fall into the gray area between the dirt poor and the insured classes don't qualify for Medicaid and can't afford the premiums for any sort of insurance (Obamacare was/is a total joke).

Many so-called "blue collar" jobs either offer no insurance or bottom-tier insurance with huge deductibles.